Loss of nocturnal blood pressure fall after liver transplantation during immunosuppressive therapy

Hypertension, which develops after organ transplantation during immunosuppression with cyclosporine (CSA), is often associated with a loss of nocturnal decrease in blood pressure. Few data correlate circadian blood pressure patterns before transplant with those observed at fixed time points after transplant, or address the role of alternate immunosuppressive agents such as FK506. FK506 is unrelated structurally to CSA and less often leads to hypertension early after transplant. The present study compared nocturnal blood pressure patterns in patients with end-stage liver disease (ESLD) before transplant to those of transplant recipients receiving either FK506 (0.15 mg/kg/day) plus prednisone or CSA (2 to 3 mg/kg/day) plus prednisone and azathioprine after orthotopic liver transplantation. Overnight ambulatory blood pressure profiles were studied in 13 pretransplant ESLD patients and in 34 patients (FK506: n = 13; CSA: n = 21) treated with different steroid doses (24 ± 11 mg/day FK506; 34 ± 3 mg/day CSA), according to protocol, 4 weeks (range, 2 to 7 weeks) after liver transplant. Mean blood pressure and heart rate values from awake and nocturnal 5-h time blocks were compared to 13 normotensive control subjects. Patients with ESLD were normotensive and maintained a normal nocturnal blood pressure fall (125 ± 3/74 ± 2 mm Hg awake; 109 ± 3/60 ± 2 mm Hg nocturnal). Awake ambulatory blood pressures were higher in CSA patients than in FK506 patients (148 ± 3/95 ± 2 v 128 ± 3/78 ± 2 mm Hg, respectively; P< .01), despite reduced glomerular filtration rates in both transplant groups. Both immunosuppressive regimens led to a loss of nocturnal blood pressure fall, as compared to ESLD patients or normotensive controls. Nocturnal heart rates were higher in ESLD and transplant patients, but decreased from awake levels similarly in all groups. These data demonstrate that despite high heart rates, ESLD patients maintain normal circadian blood pressure patterns before transplantation with disturbances of circadian blood pressure appearing soon after liver transplantation with either FK506 (plus glucocorticoid) or CSA (plus glucocorticoid) immunosuppression. These disturbances are not limited to patients developing hypertension.